OBJECTIVES: Fragmentation of continuity of care impacts the health system's performance. It severely affects people with multimorbidity and high risk, requiring coordinated care that avoids preventable complications. The Centro de Innovación en Salud ANCORA UC (CISAUC), together with the Servicio de Salud Metropolitano Sur Oriente (SSMSO) and the National Health Fund (FONASA), implemented a transitional care strategy for high-risk adults with multimorbidity at three hospitals of the southeast of Santiago. The study aimed to evaluate the impact on inpatient services utilization of high-risk adults with multimorbidity in Chile.

METHODS: A cohort study was performed between 2017 and 2019 with 137 hospitalizations from exposed patients and 167 from unexposed patients.

RESULTS: The results significantly impacted the length of bed stays (IRR 0.85; 95% CI 0.58-1.24). The implementation process showed that the role of the transition nurse merged with the clinical activities and was able to impact patients, their families, and the continuity of care, where training and continuous support were key aspects of success.

CONCLUSIONS: The study provides a detailed description of the intervention strategy, the limitations, and the facilitators contributing to its spread and scale-up. We conclude that complex interventions are feasible to install and sustain overtime in the Chilean context.